SUMMARY OF BENEFITS CONNECTICUT. mycigna Medical Plan BENEFITS PHYSICIAN SERVICES PREVENTIVE CARE INPATIENT SERVICES. mycigna Health Savings 3400

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1 BENEFITS This plan is available statewide for residents living in Connecticut In-network mycigna Health Savings 3400 Out-of-network This plan is intended to comply with the federal Patient Protection and Affordable Care Act. Provisions are subject to change as additional regulatory guidance becomes available. Individual Deductible (Medical and pharmacy) $3,400 $12,500 Family Deductible (Medical and pharmacy) $6,800 $25,000 Individual/family deductible is satisfied when each member has reached their annual individual deductible or when the total annual family deductible amount has been reached by any combination of family members. Coinsurance* Individual Out-of-Pocket Maximum $6,350 $25,000 Family Out-of-Pocket Maximum $12,700 $50,000 Individual/family copays, deductibles, coinsurance and pharmacy charges apply to the out-of-pocket maximum. PHYSICIAN SERVICES Please visit to review the network participating physicians and hospitals for your plan. If you choose to visit a physician, hospital or provider out-of-network you will pay the out-of-network benefit and the difference in the amount that Cigna reimburses for such services and the amount charged by the physician, hospital or provider, except for emergency services. Primary Care Physician (Office visit) Specialist Physician (Office visit) Office Related Services PREVENTIVE CARE Preventive Care for All Ages (Routine physicals and other preventive services) INPATIENT SERVICES Facility Services (Inpatient room and board, lab & x-ray, operating room, etc.) You pay 0% deductible waived Physician Services * Amount you pay for covered medical services. Out-of-network you may pay more, if the provider s charges exceed the amount Cigna reimburses for billed services CT 11/13 Page 1 of 6

2 BENEFITS In-network mycigna Health Savings 3400 Out-of-network OUTPATIENT SERVICES Lab, X-ray and Ultrasound CT/PET Scans and MRI Cardiac & Pulmonary Rehabilitation Unlimited visits Short-Term Rehabilitative Therapy Physical, Occupational and Speech Therapy- 40 visits. Chiropractic Care- 20 visits. Calendar Year maximums, services are combined in- and out-of-network. Outpatient Surgery (Facility) Outpatient Surgery (Physician services) EMERGENCY AND URGENT CARE SERVICES Hospital Emergency Room Urgent Care Services Ambulance All medically necessary transport OTHER HEALTH CARE FACILITIES AND SERVICES Skilled Nursing Facility Calendar year maximum of 90 days, combined in- and out-of-network. Home Health Calendar year maximum of 100 days, combined in- and out-of-network. You pay 25% after deductible Hospice DURABLE MEDICAL EQUIPMENT (DME) Durable Medical Equipment MENTAL HEALTH & SUBSTANCE ABUSE Inpatient (Includes acute, partial & residential treatment) Outpatient (Includes individual, group & intensive outpatient treatment) Page 2 of 6

3 BENEFITS In-network mycigna Health Savings 3400 Out-of-network PRESCRIPTION DRUGS (RETAIL & HOME DELIVERY) In the event that you request a brand-name drug that has a therapeutically generic equivalent, you will pay the difference between the cost in which the brand name drug exceeds the cost of the generic drug, in addition to the generic coinsurance amount indicated below. PRESCRIPTIONS FILLED AT RETAIL Please visit to review the retail pharmacies that are in-network and to see the drugs covered under this plan. TIER 1: Retail Preferred Generics (Available at the lowest cost) TIER 2: Retail Non-preferred Generics (Medications at a higher cost than Tier 1) TIER 3: Retail Preferred Brands (Brand-name drugs at a lower cost than Tier 4) TIER 4: Retail Non-preferred Brands (A mix of non-preferred brand-name and generic drugs at a higher cost than Tier 2 and Tier 3) TIER 5: Retail Specialty (Drugs for complex chronic conditions) PRESCRIPTIONS FILLED THROUGH HOME DELIVERY Cigna Home Delivery is your in-network provider to help you save money on medications. Once you are a customer visit mycigna.com or call for more information. TIER 1: Home Delivery Preferred Generics (Available at the lowest cost) TIER 2: Home Delivery Non-preferred Generics (Medications at a higher cost than Tier 1) TIER 3: Home Delivery Preferred Brands (Brand-name drugs at a lower cost than Tier 4) TIER 4: Home Delivery Non-preferred Brands (A mix of non-preferred brand name and generic drugs at a higher cost than Tier 3) TIER 5: Home Delivery Specialty (Drugs for complex chronic conditions) This summary contains highlights only. Page 3 of 6

4 2014 PLAN EXCLUSIONS AND LIMITATIONS Any amounts in excess of maximum amounts of Covered Expenses stated in this Policy. Services not specifically listed as Covered Services in this Policy. Services or supplies that are not Medically Necessary. Services or supplies that Cigna considers to be for Experimental Procedures or Investigative Procedures, except as described in the Policy. Services received before the Effective Date of coverage. Services received after coverage under this Policy ends. Services for which you have no legal obligation to pay or for which no charge would be made if you did not have health plan or insurance coverage. For or in connection with an Injury or Illness arising out of, or in the course of, any employment for wage or profit. For medical benefits, this will not apply to any of the Policyholder s partners, proprietors or corporate officers. However, if payment is made for expenses in the event that third-party liability is determined and satisfied (whether by settlement, judgment, arbitration or otherwise), Cigna shall be refunded the lesser of: (a) the amount of Cigna s payment for such expenses; or (b) the amount actually received from the third party for such expenses. In the event that a workers compensation claim is filed, Cigna shall have a lien on the proceeds of any award or settlement to the extent of its payment of benefits. Any services provided by a local, state or federal government agency, except when payment under this Policy is expressly required by federal or state law. Any services required by state or federal law to be supplied by a public school system or school district. If the Insured Person is enrolled for Medicare part A, B or D, Cigna will provide claim payment according to this Policy minus any amount paid by Medicare, not to exceed the amount Cigna would have paid if it were the sole insurance carrier. Any services for which payment may be obtained from any local, state or federal government agency (except Medicaid). Veterans Administration Hospitals and Military Treatment Facilities will be considered for payment according to current legislation. Court-ordered treatment or hospitalization, unless such treatment is prescribed by a Physician and listed as covered in this plan. Professional services or supplies received or purchased directly or on your behalf by anyone, including a Physician, from any of the following: Yourself or your employer; A person who lives in the Insured Person s home, or that person s employer; A person who is related to the Insured Person by blood, marriage or adoption, or that person s employer. Custodial Care. Inpatient or outpatient services of a private duty nurse. Except as specifically stated under Home Health Care in the section of this Policy titled Comprehensive Benefits, What the Policy Pays For. Inpatient room and board charges in connection with a Hospital stay primarily for environmental change or physical therapy; Custodial Care or rest cures; services provided by a rest home, a home for the aged, a nursing home or any similar facility service. Assistance in activities of daily living, including but not limited to: Bathing, eating, dressing, or other Custodial Care, self-care activities or homemaker services, and services primarily for rest, domiciliary or convalescent care. Inpatient room and board charges in connection with a Hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Dental services, dentures, bridges, crowns, caps or other Dental Prostheses, extraction of teeth or treatment to the teeth or gums, except as specifically provided in this Policy. Orthodontic Services, braces and other orthodontic appliances including orthodontic services for Temporomandibular Joint Dysfunction, except as described in the Policy. Dental Implants: Dental materials implanted into or on bone or soft tissue or any associated Page 4 of 6 procedure as part of the implantation or removal of dental implants. Hearing aids including but not limited to semi implantable hearing devices, audient bone conductors and Bone-Anchored Hearing Aids (BAHAs), except as specifically provided in this Policy. For the purposes of this exclusion, a hearing aid is any device that amplifies sound. Routine hearing tests except as specifically provided in this Policy under Preventive Care and Newborn Hearing Benefits. Genetic screening or preimplantation genetic screening: General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease. Optometric services, eye exercises including orthoptics, eyeglasses, contact lenses, routine eye exams, and routine eye refractions, except as specifically stated in this Policy under Pediatric Vision. An eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), astigmatism and/or farsightedness (presbyopia). Outpatient speech therapy, except as specifically stated in this Policy. Cosmetic surgery or other services for beautification, to improve or alter appearance or self-esteem or to treat psychological or psychosocial complaints regarding one s appearance including macromastia or gynecomastia surgeries; surgical treatment of varicose veins; abdominoplasty/panniculectomy; rhinoplasty. This exclusion does not apply to Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy or lumpectomy. Aids or devices that assist with nonverbal communication, including but not limited to communication boards, prerecorded speech devices, laptop computers, desktop computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert systems for the deaf and memory books, except as specifically stated in this Policy.

5 2014 PLAN EXCLUSIONS AND LIMITATIONS Nonmedical counseling or ancillary services, including but not limited to: Education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back to school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities and developmental delays Services for redundant skin surgery, removal of skin tags, acupressure, acupuncture, craniosacral/cranial therapy, dance therapy, movement therapy, applied kinesiology, rolfing, prolotherapy and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions, regardless of clinical indications. Procedures, surgery or treatments to change characteristics of the body to those of the opposite sex including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery. This includes any medical, surgical or psychiatric treatment or study related to sex change. Treatment of sexual dysfunction impotence and/or inadequacy except if this is a result of an Accidental Injury, organic cause, trauma, infection, or congenital disease or anomalies. Reversal of male or female voluntary Sterilization. Infertility services such as Donor charges and services; Gestational carriers and surrogate parenting arrangements; and experimental, investigational or unproven infertility procedures or therapies. All non-prescription Drugs, devices and/or supplies, except as described in the Prescription Drug Benefits section of the Policy. Injectable drugs (self-injectable medications) that do not require Physician supervision are covered under the Prescription Drug benefits of this Policy. All non-injectable prescription drugs, injectable prescription drugs that do not require Physician supervision and are typically considered self administered drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the Prescription Drug benefits of this Policy. Any Infusion or Injectable Specialty Prescription Drugs that require Physician supervision, except as otherwise stated in this Policy. Infusion and Injectable Specialty drugs include, but are not limited to, hemophilia factor and supplies, enzyme replacements and intravenous immunoglobulin. Cryopreservation of sperm or eggs, or storage of sperm for artificial insemination (including donor fees). Fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review Physician s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery. Blood administration for the purpose of general improvement in physical condition. Orthopedic shoes (except when joined to braces) or shoe inserts, including orthotics, except for Insureds with the diagnosis of diabetes. Services primarily for weight reduction or treatment of obesity including morbid obesity, or any care which involves weight reduction as a main method for treatment. This includes any morbid obesity surgery, even if the Insured Person has other health conditions that might be helped by a reduction of obesity or weight, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or weight reduction. Routine physical exams or tests, that do not directly treat an actual illness, injury or condition, including those required by employment or government authority, physical exams required for or by an employer, or for school, or sports physicals, except as otherwise specifically stated in this Plan. Therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long-term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected. Page 5 of 6 Telephone, and Internet consultations or other services which under normal circumstances are expected to be provided through face-to-face clinical encounters. Items which are furnished primarily for personal comfort or convenience (air purifiers, air conditioners, humidifiers, exercise equipment, treadmills, spas, elevators and supplies for hygiene or beautification, including wigs except as specifically provided in the treatment of cancer, etc.). Massage therapy. Educational services except for Diabetes Self- Management Training Program, and as specifically provided or arranged by Cigna. Nutritional counseling or food supplements, except as stated in this Policy. Durable medical equipment not specifically listed as Covered Services in the Covered Services section of this Policy. Excluded durable medical equipment includes, but is not limited to: Orthopedic shoes or shoe inserts; air purifiers, air conditioners, humidifiers; exercise equipment, treadmills; spas; elevators; supplies for comfort, hygiene or beautification; disposable sheaths and supplies; correction appliances or support appliances and supplies such as stockings, and consumable medical supplies other than ostomy supplies and urinary catheters, including, but not limited to, bandages and other disposable medical supplies, skin preparations and test strips except as otherwise stated in this Policy. Physical, Occupational and/or Speech Therapy/ Medicine except when provided during an inpatient Hospital confinement or as specifically stated in the Benefit Schedule and under Services for Short-term Rehabilitation Therapy in the section of this Policy titled Comprehensive Benefits, What the Policy Pays For. Any Drugs, medications, or other substances dispensed or administered in any outpatient setting except as specifically stated in this Policy. This includes, but is not limited to, items dispensed by a Physician.

6 2014 PLAN EXCLUSIONS AND LIMITATIONS Syringes, except as stated in the Policy. All Foreign Country Provider charges are excluded under this Policy except as specifically stated under Treatment received from Foreign Country Providers in the section of this Policy titled Comprehensive Benefits, What the Policy Pays For. Growth Hormone Treatment except when such treatment is medically proven to be effective for the treatment of documented growth retardation due to deficiency of growth hormones, growth retardation secondary to chronic renal failure before or during dialysis, or for patients with AIDS wasting syndrome. Services must also be clinically proven to be effective for such use and such treatment must be likely to result in a significant improvement of the Insured Person s condition. Growth hormone treatment for idiopathic short stature or improved athletic performance is not covered under any circumstances. Routine foot care including the cutting or removal of corns or calluses; the trimming of nails, routine hygienic care and any service rendered in the absence of localized Illness, Injury or symptoms involving the feet, except for the treatment of diabetes. Charges for which we are unable to determine our liability because the Insured Person failed, within 60 days, or as soon as reasonably possible to: (a) authorize us to receive all the medical records and information we requested; or (b) provide us with information we requested regarding the circumstances of the claim or other insurance coverage. Charges for the services of a standby physician. Charges for animal to human organ transplants. Charges for elective abortions. Claims received by Cigna after 15 months from the date service was rendered, except in the event of a legal incapacity PLAN IMPORTANT DISCLOSURES Rates will vary by plan design and the plan deductible, copay, coinsurance and out-of-pocket maximums selected. Rates may vary based on age, family size, geographic location (residential zip code) and tobacco use. Rates for new medical policies with an effective date on or after 01/01/2014 are guaranteed through 12/31/2014. After the initial guarantee, rates are subject to change upon 30 days notice. This medical insurance policy (CTINDCH052013) has exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued. Applications are accepted during annual open enrollment period, or within 60 calendar days of a qualifying event. Benefits are provided only for those services that are medically necessary as defined in the policy and for which the insured person has benefits. For costs, and additional details about coverage, contact Cigna Health and Life Insurance Company at 900 Cottage Grove Rd., Hartford, CT or call GET.Cigna. ( ). Cigna, GO YOU, and the Tree of Life logo are registered service marks and Cigna Home Delivery Pharmacy is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries, and not by Cigna Corporation. Such subsidiaries include Cigna Health and Life Insurance Company (CHLIC), Tel-Drug, Inc., and Tel-Drug of Pennsylvania, L.L.C. Cigna Home Delivery Pharmacy refers to Tel-Drug, Inc. and Tel-Drug of Pennsylvania, L.L.C CT 11/ Cigna. Some content provided under license. Page 6 of 6